Takotsubo cardiomyopathy systematic review: Pathophysiologic process, clinical presentation and diagnostic approach to Takotsubo cardiomyopathy

Investigating the Interplay between Cardiovascular and Neurodegenerative Disease

Neurological diseases, including neurodegenerative diseases (NDDs), are the primary cause of disability worldwide and the second leading cause of death. The chronic nature of these conditions and the lack of disease-modifying therapies highlight the urgent need for developing effective therapies. To accomplish this, effective models of NDDs are required to increase our understanding of underlying pathophysiology and for evaluating treatment efficacy. Traditionally, models of NDDs have focused on the central nervous system (CNS). However, evidence points to a relationship between systemic factors and the development of NDDs. Cardiovascular disease and related risk factors have been shown to modify the cerebral vasculature and the risk of developing Alzheimer's disease. These findings, combined with reports of changes to vascular density and blood-brain barrier integrity in other NDDs, such as Huntington's disease and Parkinson's disease, suggest that cardiovascular health may be predictive of brain function. To evaluate this, we explore evidence for disruptions to the circulatory system in murine models of NDDs, evidence of disruptions to the CNS in cardiovascular disease models and summarize models combining cardiovascular disruption with models of NDDs. In this study, we aim to increase our understanding of cardiovascular disease and neurodegeneration interactions across multiple disease states and evaluate the utility of combining model systems.

Base-to-apex Gradient Pattern Assessed by Cardiovascular Magnetic Resonance in Takotsubo Cardiomyopathy

OBJECTIVES

The purpose of this study was to investigate the base-to-apex gradient strain pattern as a noncontrast cardiovascular magnetic resonance (CMR) parameter in patients with Takotsubo cardiomyopathy (TTC) and determine whether this pattern may help discriminate TTC from patients with anterior myocardial infarction (AMI).

MATERIALS AND METHODS

A total of 80 patients were included in the analysis: 30 patients with apical ballooning TTC and 50 patients with AMI. Global and regional ventricular function, including longitudinal (LS), circumferential (CS), and radial strain (RS), were assessed using CMR. The base-to-apex LS, RS, and CS gradients, defined as the peak gradient difference between averaged basal and apical strain, were calculated.

RESULTS

The base-to-apex RS gradient was impaired in TTC patients compared with the AMI group (14.04 ± 15.50 vs. -0.43 ± 11.59, P =0.001). Conversely, there were no significant differences in the base-to-apex LS and CS gradients between the AMI group and TTC patients (0.14 ± 2.71 vs. -1.5 ± 3.69, P =0.054: -0.99 ± 6.49 vs. ±1.4 ± 5.43, P =0.47, respectively). Beyond the presence and extension of LGE, base-to-apex RS gradient was the only independent discriminator between TTC and AMI (OR 1.28; 95% CI 1.08, 1.52, P =0.006) in multivariate logistic regression analysis.

CONCLUSION

The findings of this study suggest that the pattern of regional myocardial strain impairment could serve as an additional noncontrast CMR tool to refine the diagnosis of TTC. A pronounced base-to-apex RS gradient may be a specific left ventricle strain pattern of TTC.

Rescue balloon pulmonary angioplasty for refractory heart failure in chronic thromboembolic pulmonary hypertension complicated with takotsubo cardiomyopathy

Balloon pulmonary angioplasty (BPA) seems promising for treating critically ill patients with chronic thromboembolic pulmonary hypertension (CTEPH) because of its less invasive and stepwise nature. However, there are only a few reports on rescue BPA. Herein, we present a case of CTEPH and takotsubo cardiomyopathy in an 82-year-old female. Despite treatment with catecholamines and intra-aortic balloon pumping, low output syndrome due to right heart failure with CTEPH and left heart failure with takotsubo cardiomyopathy did not improve. Therefore, rescue BPA for CTEPH was performed; this immediately improved the patient's hemodynamics.

Learning objective

Rescue balloon pulmonary angioplasty (BPA) is an option for critically ill patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) that requires immediate improvement of hemodynamics. BPA strategy initially aimed at partial improvement of pulmonary circulation would be useful in treating CTEPH complicated by refractory right and left heart failure due to coexisting left-sided heart disease.

Can longitudinal strain analysis differentiate between Takotsubo syndrome and acute coronary syndrome?

BACKGROUND

Takotsubo syndrome (TTS) is characterized by transient abnormalities of myocardial contractility. Noninvasive tests are currently being sought to differentiate TTS from acute coronary syndrome (ACS).

THE AIM OF THE STUDY

To evaluate the prevalence of TTS and echocardiographic parameters to distinguish apical TTS from acute anterior wall infarction.

MATERIAL AND METHODS

The medical records of patients with suspected TTS, hospitalized in the Department of Cardiology (TTS group n = 18) were analyzed. The control group included patients with STEMI of the left ventricle anterior wall and anterior and lateral wall (STEMI group n = 17). Standard transthoracic echocardiography (TTE) was supplemented with segmental longitudinal strain (LS) assessment with the use of acoustic marker tracking.

RESULTS

A statistically significant difference was observed in the second cardiac troponine I (CTNI) measurement (TTS: 3241.2 ng/L vs. STEMI: 12032.6 ng/L; p < 0.05). A significant difference in left and right ventricular size was observed on TTE. Left ventricular end-diastolic and end-systolic volumes were considerably smaller in TTS group; (86.1 vs. 104 ml and 48.1 vs. 74.1 ml, respectively). LS were significantly higher (in absolute values) in patients with TTS than in those with STEMI in the apical and middle lateral segments, LS in the apical four-chamber view (apSept -14.9 vs. -8.9; apLat -14.8 vs. -6.84; midLat -13.26 vs. -9.11).

CONCLUSIONS

Patients with TTS are characterized by a different LS pattern in the apical segments of the left ventricle compared to patients with STEMI. TTE examination with LS remains insufficient to distinguish TTS from ACS at the early stage of diagnosis.

Global reports of takotsubo (stress) cardiomyopathy following COVID-19 vaccination: A systematic review and meta-analysis

Concerns have been raised recently about takotsubo cardiomyopathy (TCM) after receiving COVID-19 vaccines, particularly the messenger RNA (mRNA) vaccines. The goal of this study was to compile case reports to provide a comprehensive overview of takotsubo cardiomyopathy (TCM) associated with COVID-19 vaccines. A systematic literature search was conducted in PubMed, Scopus, Embase, Web of Science, and Google Scholar between 2020 and June 1, 2022. The study included individuals who developed cardiac takotsubo cardiomyopathy from receiving COVID-19 vaccinations. Ten studies, including 10 cases, participated in the current systematic review. The mean age was 61.8 years; 90 % were female, while 10 % were male. 80 % of the patients received the mRNA COVID-19 vaccine, while 20 % received other types. In addition, takotsubo cardiomyopathy (TCM) occurred in 50 % of patients receiving the first dose and another 40 % after the second dose of COVID-19 vaccines. Moreover, the mean number of days to the onset of symptoms was 2.62 days. All cases had an elevated troponin test and abnormal ECG findings. The left ventricular ejection fraction (LVEF) was lower than 50 % in 90 % of patients. In terms of the average length of hospital stay, 50 % stayed for 10.2 days, and all cases recovered from their symptoms. In conclusion, takotsubo (stress) cardiomyopathy (TCM) complications associated with COVID-19 vaccination are rare but can be life-threatening. Chest pain should be considered an alarming symptom, especially in those who have received the first and second doses of the COVID-19 vaccine.

Atrial Impairment as a Marker in Discriminating Between Takotsubo and Acute Myocarditis Using Cardiac Magnetic Resonance

PURPOSE

The purpose of this study was to comprehensively compare the left and right atrium strain and strain rate (SR) parameters by cardiac magnetic resonance (CMR) between patients with Takotsubo (TS) and patients with acute myocarditis (AM).

MATERIALS AND METHODS

We retrospectively enrolled 3 groups of patients: TS (n=18), AM (n=14), and 11 healthy subjects. All the patients had complete CMR data for features tracking assessment.Differences in reservoir, conduit strain (εe), conduit strain rate (SRe), and booster phase of biatrial strain were analyzed between the groups using analysis of variance and multivariate analysis of covariance analyses. Intraobserver and interobserver reproducibility was assessed for all strain and SR parameters using intraclass correlation coefficients and Bland-Altman analysis.

RESULTS

Atrial strain was feasible in all patients and controls. In TS, left atrium (LA) reservoir strain (εs), reservoir SR, εe, and SRe were significantly lower compared with the other groups (P=0,001 for all). multivariate analysis of covariance analysis showed association of these parameters after correction for age and sex, while LA booster deformation (εa and SRa) strain parameters were preserved. LA SRe proved to have excellent sensitivity in differentiating patients with TS from those with AM (areas under the curves of 0.903, 95% confidence interval: 0.81-0.99).Biatrial strain and SR parameters showed good (excellent) intraobserver and interobserver reproducibility (ranged between 0.61 to 0.96 and 0.50 to 0.90, respectively).

CONCLUSION

Compared with AM, patients with TS showed significantly decreased LA reservoir, conduit strain, and SR parameters. Therefore, LA strain assessment may have a role in discriminating between TS and AM.

Negative Impact of the UEFA European Soccer Championship on Central Hemodynamics and Arterial Stiffness: A Multicenter Study

(1) Background: watching sporting events may trigger cardiovascular events by elevating emotional stress levels. The underlying reasons and specific populations at risk are not well defined. (2) Methods: we conducted a multicenter prospective trial at three German sites during the UEFA Soccer EC 2012 and 2021 comprising 52 healthy participants (noCVD) and 18 patients hospitalized with cardiovascular disease (CVD). Subjects were studied during matches of the German national team (GP) as well as corresponding matches without German participation (noGP). Peripheral and central blood pressure (BP) and parameters of arterial stiffness were measured (Mobil-O-Graph™, I.E.M., Stolberg, Germany) before, during, and after the matches. (3) Results: in terms of CVD, peripheral as well as central BP and heart rate increased significantly during GP as well as noGP matches and remained elevated beyond the end of the matches. Likewise, arterial stiffness parameters and vascular resistance were higher during the matches and remained elevated after the matches. No consistent significant differences were found between GP and noGP matches. (4) Conclusions: this is the first study on real-life changes in hemodynamics during sport-associated emotional stress, with comparison between noCVD and CVD. We found that alterations were profound in CVD and remained elevated even after the matches.

Atypical Takotsubo cardiomyopathy presenting as acute coronary syndrome: A case report

BACKGROUND

Takotsubo cardiomyopathy (TS) is a rare acute cardiac disease with clinical features, symptoms, and electrocardiographic manifestations similar to those of acute myocardial infarction. We present the case of a patient with TS caused by a pheochromocytoma, which was confirmed by the postoperative pathology. Furthermore, we present the patient's subsequent management, treatment, and outcome.

CASE SUMMARY

A 64-year-old woman was admitted to the hospital with episodic chest pain and palpitations, electrocardiogram (ECG) findings suggestive of high lateral wall myocardial infarction, echocardiogram showing left ventricular wall segmental motion abnormalities, and elevated levels of the myocardial marker troponin. The patient underwent coronary angiography, which revealed unobstructed blood flow without obvious stenosis. During their hospitalization, the patient had paroxysmal elevation of blood pressure accompanied by palpitations and profuse sweating, with elevated blood catecholamine levels during seizures. Subsequent computerized tomography of the adrenal glands revealed the presence of a nodule in the right adrenal, which was resected and determined to be an adrenal pheochromocytoma. Therefore, the diagnosis of pheochromocytoma-induced atypical TS was made. The patient had an uneventful postoperative recovery.

CONCLUSION

Cardiologists should consider pheochromocytoma in patients with TS. Early detection allows timely intervention, benefiting patients.

Reverse Takutsubo Cardiomyopathy in a Patient with Phlegmasia Cerulea Dolens

Reverse takotsubo cardiomyopathy (rTTC) is a rare variant of takotsubo cardiomyopathy (TTC) which is characterized by reversible left ventricular (LV) dysfunction. Emotional and physical stress have been implicated in triggering TTC especially in postmenopausal women. TTC and its variants are becoming more recognized due to the widespread adoption of early coronary angiography in the setting of acute coronary syndromes. A man in his late 50s presented to the emergency department with left lower extremity pain, swelling, and cyanosis. Clinical assessment was consistent with phlegmasia cerulea dolens, with deep venous thrombosis detected by venous duplex ultrasound. During his admission, he developed clinical and EKG findings suggestive of acute coronary syndrome. Emergent coronary angiography and ventriculography revealed basal and midventricular hypokinesis with hyperdynamic left ventricular apex, depressed LV dysfunction without coronary artery obstruction diagnostic of reverse takotsubo cardiomyopathy. Venous thromboembolism is a rare finding but has been associated with takotsubo cardiomyopathy and should be considered in the appropriate setting.

Transient stress-related hyperviscosity and endothelial dysfunction in Takotsubo syndrome: a time course study

Takotsubo syndrome (TTS) is an acute and usually reversible heart failure syndrome, frequently associated with emotional or physical stress. Its pathophysiology remains largely unclear, although several mechanisms related to catecholaminergic storm have been proposed. In this study we analyzed during the acute phase of TTS and at follow-up both hemorheological parameters and biomarkers of endothelial damage, whose time course has never been fully explored. In 50 TTS women, we analyzed several hemorheological parameters [whole blood viscosity (WBV) at 0.512 s^-1 and at 94.5 s^-1, plasma viscosity (PLV), erythrocyte deformability and aggregation index] as well as biomarkers of endothelial dysfunction [von Willebrand Factor (vWF), Plasminogen activator inhibitor-1 and factor VIII levels] during the acute phase and after a median 6 months follow-up. These variables were also assessed in 50 age-matched healthy women. Respect to follow-up, in the acute phase of TTS we observed higher values of white blood cell count, fibrinogen, WBV at low and high shear rates, PLV, erythrocyte aggregation index and lower values of erythrocyte elongation index. Moreover, all biomarkers of endothelial dysfunction resulted significantly higher in the acute phase. During follow-up WBV at 94.5 s^-1, erythrocyte elongation index and vWF resulted significantly altered with respect to controls. The results of this study confirm the role of hyperviscosity and endothelial dysfunction in TTS pathophysiology. Moreover, they suggest the persistence of alterations of erythrocyte deformability and endothelial dysfunction even beyond the acute phase that could be the target of therapeutic strategies also during follow-up.

Could CMR Tissue-Tracking and Parametric Mapping Distinguish Between Takotsubo Syndrome and Acute Myocarditis? A Pilot Study

RATIONALE AND OBJECTIVE

Takotsubo syndrome (TS) is a transient and often misdiagnosed form of left ventricular dysfunction. Acute myocarditis (AM) is usually included in TS differential diagnosis. The aim of this study is to assess the role of cardiac magnetic resonance imaging coupled with tissue-tracking technique (CMR-TT) and parametric mappings analysis in discriminating between TS and AM.

MATERIALS AND METHODS

We retrospectively enrolled three groups: patients with TS (n = 12), patients with AM (n = 14), and 10 healthy controls. All the patients had a comprehensive CMR examination, including the assessment of global and segmental longitudinal strain, circumferential strain, radial strain (RS), and parametric mapping.

RESULTS

The analysis of variance was used to compare the different groups. In TS patients, basal RS, global T1 mapping, global T2 mapping, mid T2 mapping, apical T1 and T2 mapping were statistically significantly different compared with the other groups. MANCOVA analysis confirmed that the association between myocardial strain data and parametric mapping was independent on age and sex. Apical T1 and T2 mapping proved to have a good performance in differentiating TS from AM (area under the curves of 0.908 and 0.879, respectively).

CONCLUSION

Basal RS and apical tissue mapping analysis are the most advanced CMR-derived parameters in making a differential diagnosis between TS and AM.

Takotsubo syndrome associated with cardioversion: a systematic review

Background

Direct current cardioversion is a well-established and safe procedure to restore normal sinus rhythm for atrial and ventricular arrhythmias. Takotsubo syndrome has been rarely described with cardioversion. We reviewed the literature for descriptions of Takotsubo syndrome associated with the stress of cardioversion, to better understand its risks.

Methods

We queried MEDLINE, EMBASE, Google Scholar and Cochrane for cases of Takotsubo syndrome secondary to synchronized cardioversion as defined by Mayo Clinic Diagnostic Criteria.

Results

We identified 11 cases of cardioversion-associated Takotsubo syndrome. Average age was 76 years (range: 61–87 years) and most (10 out of 11, 91%) were female. Diagnosis was made soon after cardioversion (median: 10 h, range: 0–48 h). Only 2 of 11 had ST elevations noted, while apical ballooning was noted in all cases. Pulmonary edema developed in 6 and cardiogenic shock developed in 5 patients. The median recovery time was 7 days (range: 3–11).

Conclusions

Cardioversion-associated TS has an overall favorable outcome with complete recovery in most cases. A higher risk of this complication may exist for elderly females undergoing synchronized cardioversion.

Stress-Induced Cardiomyopathy Raising Concern for Myocardial Ischemia

Stress-induced cardiomyopathy (SIC), or Takotsubo syndrome, is considered a reversible dysfunction of the left ventricle that may mimic an acute coronary syndrome (ACS). Patients may present with chest pain, dyspnea, syncope, or other serious complications including cardiogenic shock, ventricular arrhythmias, and thrombus formation. Diagnostic criteria for SIC include several factors, including electrocardiogram changes, cardiac biomarker elevations, ventricular regional wall abnormalities on echocardiogram, and absence of occlusive coronary disease on coronary angiography. There is no standardized protocol for the treatment of SIC, although the current consensus is that patients should be risk-stratified, managed for complications, and treated with supportive therapy accordingly. In this case study, we present an 85-year-old female who presented with one month of fatigue, lower extremity weakness, and exertional dyspnea with chest pressure. She received a cardiac workup which revealed lab and imaging findings consistent with SIC. She received treatment for SIC, pericarditis, and Clostridium difficile colitis.

Dopamine D1/D5 Receptor Signaling Is Involved in Arrhythmogenesis in the Setting of Takotsubo Cardiomyopathy

Background

Previous studies suggested involvement of non-ß-adrenoceptors in the pathogenesis of Takotsubo cardiomyopathy (TTC). This study was designed to explore possible roles and underlying mechanisms of dopamine D1/D5 receptor coupled signaling in arrhythmogenesis of TTC.

Methods

Human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) were challenged by toxic concentration of epinephrine (Epi, 0.5 mM for 1 h) for mimicking the catecholamine excess in setting of TTC. Specific receptor blockers and activators were used to unveil roles of D1/D5 receptors. Patch clamp, qPCR, and FACS analyses were performed in the study.

Results

High concentration Epi and two dopamine D1/D5 receptor agonists [(±)-SKF 38393 and fenoldopam] reduced the depolarization velocity and prolonged the duration of action potentials (APs) and caused arrhythmic events in iPSC-CMs, suggesting involvement of dopamine D1/D5 receptor signaling in arrhythmogenesis associated with QT interval prolongation in the setting of TTC. (±)-SKF 38393 and fenoldopam enhanced the reactive oxygen species (ROS)-production. H₂O₂ (100 μM) recapitulated the effects of (±)-SKF 38393 and fenoldopam on APs and a ROS-blocker N-acetylcysteine (NAC, 1 mM) abolished the effects, suggesting that the ROS-signaling is involved in the dopamine D1/D5 receptor actions. A NADPH oxidases blocker and a PKA- or PKC-blocker suppressed the effects of the dopamine receptor agonist, implying that PKA, NADPH oxidases and PKC participated in dopamine D1/D5 receptor signaling. The abnormal APs resulted from dopamine D1/D5 receptor activation-induced dysfunctions of ion channels including the Na⁺ and L-type Ca²⁺ and I_Kr channels.

Conclusions

Dopamine D1/D5 receptor signaling plays important roles for arrhythmogenesis of TTC. Dopamine D1/D5 receptor signaling in cardiomyocytes might be a potential target for treating arrhythmias in patients with TTC.

Novel case of takotsubo cardiomyopathy following COVID-19 vaccination

We present an unusual case of takotsubo cardiomyopathy (TTC) following administration of the second dose of the DNA ChadOX1 nCOV-19 (AZD122) vaccination. This woman in her early 50s presented to the emergency department 8 days following her vaccine with central chest pain. Initial investigations revealed a raised troponin and evolving T wave inversion on ECG. Acute coronary syndrome management was commenced. Further investigations revealed non-obstructive coronary arteries on coronary angiography and imaging revealed hypokinesia of the anterior and anterior-septal walls in the apex and midcavity level, myocardial oedema and no infarction, all in keeping with TTC. Given the large-scale roll out of vaccinations during the COVID-19 pandemic better understanding of potential adverse events is essential. This is the first case report of TTC following a second dose of the DNA ChadOX1 nCOV-19 (AZD122) vaccination.

Impact of malnutrition on in-hospital outcomes in takotsubo cardiomyopathy

OBJECTIVE

This study assesses the effect of malnutrition on the in-hospital outcomes of patients with takotsubo cardiomyopathy (TCM).

METHODS

We performed a retrospective cohort analysis using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes for a primary diagnosis of TCM from the National Inpatient Sample database (2016-2018). A concurrent diagnosis of malnutrition was then identified, and these patients were divided into the malnutrition group and non-malnutrition group. To adjust for underlying risk factors, a multivariable logistic regression model was employed followed by a propensity score matching analysis for the malnutrition and the non-malnutrition group. We then compared the in-hospital outcomes between these two groups.

RESULTS

Among 4733 patients with a primary diagnosis of TCM, 221 (4.7%) patients with TCM were found to be malnourished. After propensity score matching, patients with TCM with malnutrition were found to have a higher mortality rate (8.3% versus 2.0%, P < 0.001), a higher rate of complications including cardiogenic shock (16.1% versus 7.0%, P < 0.001), ventricular arrhythmia (8.8% versus 3.9%, P = 0.01), acute kidney injury (24.9% versus 10.6%, P < 0.001), and acute respiratory failure (32.7% versus 17.8%, P < 0.001). There was no statistically significant difference in the incidence of cardiac arrest between the two groups. Malnutrition of severe degree was associated with a sevenfold (odds ratio 6.8, 95% confidence interval, 3.2-13.4) increased risk of in-hospital mortality compared with those without malnutrition.

CONCLUSION

Patients with malnutrition who were admitted with TCM were associated with higher rates of in-hospital mortality and complications compared with those without malnutrition.

A life-threatening reverse Takotsubo syndrome in a young breastfeeding woman: a case report

Background

Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and is usually triggered by emotional, physical, or combined stress. This syndrome has been increasingly recognized, although it remains a challenging and often misdiagnosed disorder.

Case summary

A 36-year-old breastfeeding woman was admitted with sudden dyspnoea and oppressive chest pain. On admission, she was lethargic, hypotensive, and tachycardic. The electrocardiogram showed rapid atrial fibrillation and diffuse ST-segment depression. The transthoracic echocardiogram (TTE) revealed severe LV systolic dysfunction, with midventricular and basal akinesis, compensatory apical hyperkinesia, and without intraventricular gradient. Emergent coronary angiogram showed normal coronary arteries. A presumptive diagnosis of reverse TTS with cardiogenic shock (CS) was made. The patient was transferred to the intensive care unit after intubation and inotropic and vasopressor support was initiated. During hospitalization, rapid clinical improvement was observed. In 3 days, the patient was weaned from haemodynamic support and extubated. Furthermore, β-blocker and angiotensin receptor blocker were initiated and tolerated. Cabergoline was also administered to inhibit lactation. The presumptive diagnosis was further strengthened by cardiac magnetic resonance and all triggering factors were excluded. At hospital discharge she was asymptomatic and the follow-up TTE was normal, which confirmed the diagnosis of reverse TTS.

Discussion

We present a case of a young woman, 8 months after delivery, which developed a life-threatening reverse TTS without triggering factor identified. Reverse TTS is a rare variant of TTS with different clinical features and is more likely to be complicated by pulmonary oedema and CS.

The Broken Heart: The Role of Life Events in Takotsubo Syndrome

The onset of Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is thought to be associated with some life events. This study focuses on clarifying life event characteristics and the role of triggers in the onset of TTS. Participants with TTS (n = 54) were compared to those with acute myocardial infarction (AMI; n = 52) and healthy individuals (n = 54). Using a modified version of the Interview for Recent Life Events, information about general life events perceived as stressful and triggers preceding the onset of a cardiac syndrome was collected. The assessment included the impact of these events as indicated by the participants and estimated by the interviewer; finally, the objective impact was considered. Although the number of events and the objective impact did not differ among the groups, patients with TTS reported a more negative perceived impact. Moreover, 61% of these patients objectively and subjectively reported a more stressful trigger before the onset of the disease (in the 24 h preceding the cardiac event) than those reported by patients with AMI. The dynamic between life events and individual responses could help differentiate TTS from other cardiovascular events, such as AMI. This study suggests that patients' perception of some life events (whether triggers or general life events) could represent a possible marker of TTS.

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Takotsubo cardiomyopathy (TCM), characterized by reversible ventricular dysfunction, has similar mortality to acute coronary syndrome. With the growing interest in the diagnosis of and interventions for TCM, many risk factors had been found to affect the prognosis of TCM patients, such as age, sex, and pre-existing diseases. Because of the incomplete understanding of the pathophysiologic mechanism in TCM, evidence-based medical therapy for this condition is lacking. Early intervention on risk factors may improve the outcomes of TCM. In this review, we sought to provide up-to-date evidence on risk factors and medical therapies that affect TCM outcome. We found that male sex, physical triggers, and certain comorbidities such as chronic kidney disease, malignant disease, higher body mass index, sepsis, chronic obstructive pulmonary disease, and anaemia were associated with poor TCM prognosis. In contrast, race, hyperlipidaemia, diabetes mellitus, and mood disorders were not clearly associated with TCM prognosis. We also reviewed the effect of medical therapies on TCM outcome, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, calcium channel blockers, and statins. The evidence that these medications confer a survival benefit on TCM patients is limited. Understanding these prognostic factors could help develop risk-stratification tools for TCM and establish effective prevention and interventions for this not-so-benign condition. Further multicentre clinical studies with large samples and meta-analyses of findings from previous studies are needed to address the inconsistent findings among the many potential risk factors for TCM.

Takotsubo Cardiomyopathy Precipitated By Thyroidectomy - A Case Report

Takotsubo cardiomyopathy (TC) is an acute cardiac condition triggered by emotional or physical stress. General anesthesia and sympathetic activation are possible triggers for TC. However, little is known about the role of sympathovagal activity in TC. In our report, we present a female patient, aged 62, who underwent thyroidectomy and at the end of the surgery developed cardiac complications. The patient had no chest pain, but had ST depression and negative T waves on the electrocardiogram (ECG). Cardiospecific enzyme troponin was elevated. Cardiac catheterization revealed unobstructed coronary arteries. Echo-cardiography revealed the enlargement of the left ventricle and ejection fraction of 40%. The patient was diagnosed with TC and dual antiplatelet therapy was introduced, a beta blocker and ACE inhibitor.It is possible that TC in perioperative period after thyroidectomy in this patient occured due to both sympathetic and parasympathetic activation. Probably, extraction of large thyroid induced vagal stimulation which resulted in hypotension and bradicardia. The patient was subsequently treated with adrenaline and atropine. In this case, sympathetic and parasympathetic activation in different intervals could result in the development of this condition.

Takotsubo Syndrome Associated with a New Onset Manic Episode: A case report

Takotsubo syndrome is a condition that mimics acute coronary syndrome. The exact pathogenesis of the condition is unclear but it tends to occur more frequently in elderly women and a large proportion of cases have acute, former, or chronic neurologic or psychiatric disorders. Here we describe a 55-year-old female patient, who was brought to the emergency department presenting with a new-onset manic episode characterized by grandiosity, distractibility, decreased need for sleep, and increased goal-directed behaviours. She experienced chest pain approximately two days later, and non-ST elevation myocardial infarction was observed. The emergent coronary angiogram showed patent coronary arteries, and a diagnosis of Takotsubo syndrome was made. We suggest clinical multidisciplinary vigilance for somatic complaints, especially cardiac ones, in people with psychiatric disorders in order to make timely therapeutic interventions.

Cardiomyopathies: An Overview

Background: Cardiomyopathies are a heterogeneous group of pathologies characterized by structural and functional alterations of the heart. Aims: The purpose of this narrative review is to focus on the most important cardiomyopathies and their epidemiology, diagnosis, and management. Methods: Clinical trials were identified by Pubmed until 30 March 2021. The search keywords were “cardiomyopathies, sudden cardiac arrest, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy, arrhythmogenic cardiomyopathy (ARCV), takotsubo syndrome”. Results: Hypertrophic cardiomyopathy (HCM) is the most common primary cardiomyopathy, with a prevalence of 1:500 persons. Dilated cardiomyopathy (DCM) has a prevalence of 1:2500 and is the leading indication for heart transplantation. Restrictive cardiomyopathy (RCM) is the least common of the major cardiomyopathies, representing 2% to 5% of cases. Arrhythmogenic cardiomyopathy (ARCV) is a pathology characterized by the substitution of the myocardium by fibrofatty tissue. Takotsubo cardiomyopathy is defined as an abrupt onset of left ventricular dysfunction in response to severe emotional or physiologic stress. Conclusion: In particular, it has been reported that HCM is the most important cause of sudden death on the athletic field in the United States. It is needless to say how important it is to know which changes in the heart due to physical activity are normal, and when they are pathological.

Analysis of factors affecting progression-free survival of first-line chemotherapy in older patients with advanced gastrointestinal cancer

OBJECTIVES

Few studies have investigated factors influencing the efficacy of chemotherapy in older patients with cancer. This study aimed to evaluate the usefulness of G8, geriatric assessment (GA), and factors measured in general clinical practice for evaluating progression-free survival (PFS) of first-line palliative chemotherapy in older patients with advanced gastrointestinal cancer.

MATERIALS AND METHODS

This was a prospective observational study of older patients (age ≥ 70 years) with advanced gastrointestinal cancer. The modified cut-off value of G8 was determined by referring to two or more abnormal GA conditions. The usefulness of baseline GA and G8 (conventional and modified cut-off value) was assessed according to the efficacy (PFS and disease control rate) of the administered first-line palliative chemotherapy.

RESULTS

Overall, 93 patients were evaluated between March 2017 and February 2019. A modified G8 cut-off value of ≤12 had a sensitivity and specificity of 68.9% and 46.9%, respectively. PFS was significantly prolonged in the patients with G8 > 12, serum albumin ≥3.5 g/dl, and in whom grade ≥ 3 adverse events occurred. There was no significant difference in the PFS between monotherapy and combination therapy. GA was not useful for predicting PFS prolongation or the occurrence of serious adverse events in first-line treatment.

CONCLUSION

Among older patients with advanced gastrointestinal cancer who receive first-line chemotherapy, a modified G8 cut-off value of 12 points, occurrence of grade 3 or higher adverse events, albumin levels, rather than age or performance status were predictors of PFS prolongation.

Abnormal thyroid function is common in takotsubo syndrome and depends on two distinct mechanisms: results of a multicentre observational study

BACKGROUND

Several reports have described Takotsubo syndrome (TTS) secondary to thyrotoxicosis. A complex interaction of central and peripheral catecholamines with thyroid homeostasis has been suggested. In this study, we analysed sequential thyroid hormone profiles during the acute phase of TTS.

METHODS

Thyrotropin (TSH), free T4 (FT4) and free T3 (FT3) concentrations were analysed at predefined time points in 32 patients presenting with TTS or acute coronary syndrome (ACS, n = 16 in each group) in a 2-year period in two German university hospitals. Data were compared to age- and sex-matched controls (10 samples, each of 16 subjects), and an unsupervised machine learning (ML) algorithm identified patterns in the hormone signature. Subjects with thyroid disease and patients receiving amiodarone were excluded from follow-up.

RESULTS

Among patients with TTS, FT4 concentrations were significantly higher when compared to controls or ACS. Four subjects (25%) suffered from subclinical or overt thyrotoxicosis. Two additional patients developed subclinical or overt thyrotoxicosis during stay in hospital. In four subjects (25%), FT4 concentrations were increased, despite nonsuppressed TSH concentration, representing an elevated set point of thyroid homeostasis. The thyroid hormone profile was normal in only six patients (38%) presenting with TTS.

CONCLUSION

Abnormal thyroid function is frequent in patients with TTS. Primary hyperthyroidism and an elevated set point of thyroid homeostasis are common in TTS, suggesting a stress-dependent endocrine response or type 2 thyroid allostasis. Thyroid function may be a worthwhile target in treating or preventing TTS.

The Story of a Broken Heart: Takotsubo Cardiomyopathy

Licensed independent practitioners in emergency clinical practice are tasked with differentiating acute cardiac presentations. Despite its similarity in clinical presentation to acute coronary syndrome, Takotsubo cardiomyopathy is a unique cardiac disorder characterized by a stress-induced ballooning of the myocardium. Also known as the broken heart syndrome, Takotsubo cardiomyopathy most frequently occurs after an overwhelming emotional or physical stressor. The subsequent impaired contractility of the heart places the patient at risk of complications, including acute heart failure, cardiogenic shock, thromboembolism, arrhythmias, and left ventricular outflow obstruction. Takotsubo cardiomyopathy is similar in presentation to other cardiac disorders; therefore, clinicians in emergency settings must be efficient and effective in their diagnosis of this disorder on the basis of its distinct criteria. The current article uses most recent evidence to describe the etiology, pathophysiology, diagnosis, and recommended treatment for Takotsubo cardiomyopathy to support licensed independent practitioners in emergency departments in improving patient outcomes and reducing morbidity.

Current strategies with sensing technologies to eliminate stress cardiomyopathy

Stress cardiomyopathy refers weakening of heart muscle due to the continuous stress. Generally, the severe status of stress cardiomyopathy has been revealed after damaging the muscles and measured by the physical changes in the heart system. To overcome this issue, biosensor can be used, which could eliminate the late identification stress cardiomyopathy. With biosensors, different stress markers such as epinephrine, dopamine, catecholamine, α-amylase, norepinephrine, serotonin and cortisol have been identified by a wide range of developments. These biosensors are available from laboratory to industry at the ranges of nano to macrodevices. To merge with the identification of stress cardiomyopathy, the above strategies might be utilized properly and can aid to reduce the stress-related problems. This overview gleaned the currently available biosensing methods and the associated biomarkers at various stages of the developments and implementations of stress cardiomyopathy.

COVID 19: A Stressor for Both the Patient and the Anesthesiologist

The coronavirus disease 2019  pandemic has created not only  widespread  morbidity and mortality, but a myriad of social, financial, and psychological stressors. In this setting, the medical community has seen a substantial increase in the incidences  of cardiac morbidity and mortality, and, therefore,  anesthesiologists should expect a higher incidence in the perioperative period. In this E-Challenge, the authors present a patient in whom an acute cardiac decompensation occurred secondary to an unanticipated difficult intubation, with an unexpected echocardiographic finding.

Recurrent Takotsubo cardiomyopathy triggered by emotionally stressful events: A case report

BACKGROUND

Takotsubo cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction triggered by emotional or physical stress. Only 1%-2% of patients with acute coronary syndrome are diagnosed with TCM. Although obstructive coronary artery disease is frequently considered to be the cause of chest pain, TCM should be considered in some clinical settings. In this case, clinicians did not make a timely and accurate diagnosis for TCM due to a lack of knowledge until the third hospitalization with a left ventriculogram.

CASE SUMMARY

A 55-year-old postmenopausal woman had intermittent chest pain following emotionally stressful events three times in the past 3 years. Cardiac troponin levels increased after each instance of symptom onset. A transthoracic echocardiogram showed reversible left ventricular dysfunction. The patient underwent three coronary angiograms without evidence of coronary artery disease. A left ventriculogram was first performed at the third hospitalization and revealed apical akinesia with ballooning of the apical region and consistent hypercontractile basal segments. The diagnosis of TCM was confirmed. The patient was treated with an angiotensin-converting-enzyme inhibitor (perindopril) and a β-blocker (metoprolol). No complications occurred during the patient’s hospitalization. The patient was told to avoid stressful events. During the 9-mo follow-up visit, the patient was asymptomatic with an ejection fraction of 55%.

CONCLUSION

Clinicians should be conscious of the possibility of TCM, especially in postmenopausal women presenting with clinical manifestations similar to acute coronary syndrome without coronary occlusion.

Stress cardiomyopathy following thyroidectomy in a premenopausal woman with thyroid cancer: case report and review of the literature

Stress cardiomyopathy (SC) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that SC may be associated with severe clinical complications including death and that its prevalence is probably underestimated. The disease is characterized by transient systolic and diastolic left ventricular (LV) dysfunction with a variety of wall-motion abnormalities. It predominantly affects postmenopausal women and is often preceded by an emotional or physical trigger, but the condition has also been reported with no evident trigger. The striking preponderance of postmenopausal females suggests a hormonal influence. Potentially, declining oestrogen levels after menopause increase the susceptibility to SC in women. Oestrogens can influence vasomotor tone via up-regulation of endothelial NO synthase. Also, there is evidence that oestrogens can attenuate catecholamine-mediated vasoconstriction and decrease the sympathetic response to mental stress in perimenopausal women. Rare cases of SC following thyroidectomy in premenopausal women have been described. Currently, the pathogenesis of SC remains obscure, several possible hypotheses include catecholamine induced myocardial spasm or catecholamine related myocardial stunning, metabolic disorders and coronary microvascular damage. So prompt diagnosis and optimal management are crucial to obtaining a good outcome for the patient. We report an extremely rare case of SC induced by thyroidectomy in a premenopausal woman with cancer, and share our personal experience by reviewing the literature.

Clinical characteristics and long-term outcomes of peripartum takotsubo cardiomyopathy and peripartum cardiomyopathy

Aims

Although some peripartum‐associated cardiomyopathy patients present with features that are clinically and echocardiographically similar to those of takotsubo cardiomyopathy (TCM), little is known about the diagnosis and clinical course of peripartum TCM.

Methods and results

In a tertiary hospital in Seoul, Korea, we searched the hospital database to find cardiomyopathy cases that were associated with pregnancy from January 1995 to May 2019. Applying the published diagnostic criteria, we sought peripartum cardiomyopathy (PPCM) and peripartum TCM patients for comparison. Of 31 pregnancy‐associated cardiomyopathy patients, 10 cases of peripartum TCM and 21 cases of PPCM were found. Maternal near‐miss death was significantly more common in the peripartum TCM group than in the PPCM group (100.0% vs. 57.1%, P = 0.030). Complete recovery was observed with all peripartum TCM cases, while 23.8% of the PPCM cases had residual left ventricular dysfunction. One death and one heart transplantation occurred in the PPCM group, while neither occurred in the peripartum TCM group. There was no difference between the two groups in terms of the rate of major adverse clinical events at 3 years of follow‐up [PPCM group: 26.3% (5/19) vs. TCM group: 33.3% (3/9), P = 0.750].

Conclusions

One‐third of pregnancy‐associated cardiomyopathy patients had peripartum TCM. With contemporary supportive care, both PPCM and peripartum TCM patients had a low mortality rate and excellent long‐term outcomes.

Takotsubo cardiomyopathy and pituitary apoplexy: a case report

Background

Takotsubo cardiomyopathy (TTC) has been widely recognized in recent decades and is triggered by either physical or psychological stressors.

Case presentation

A 70-year-old woman presented to the Emergency Department due to confusion, hypotension, fever, chills, and cough. She had a one-year history of diabetes insipidus. Pituitary function examination at admission revealed decreased thyroid, sex and adrenal hormones. Pituitary MRI displayed findings suggestive of nonhemorrhagic pituitary apoplexy. Electrocardiogram (ECG) revealed T-wave inversion and extended QT interval. Transthoracic echocardiogram (TTE) showed left ventricular apical dysplasia and ballooning, accompanied by reduced left ventricular ejection fraction. Coronary angiography (CAG) revealed no obvious coronary arterial stenosis. The left ventriculogram demonstrated an octopus clathrate appearance. Most ECG and TTE changes recovered 10 days later.

Conclusions

To the best of our knowledge, this is the first report of newly diagnosed TTC associated with pituitary apoplexy.

Assessment with intracoronary pressure and flow guidewire, at baseline and after intracoronary adenosine infusion, in a patient with Takotsubo syndrome

We present the case of a patient with Takotsubo syndrome assessed by intracoronary flow and pressure guidewire, showing elevation of intracoronary pressures at the level of the anterior descending artery, and thus demonstrating a new therapeutic target in a still little understood etiopathogenic entity. The results of this test have never been previously reported in Takotsubo patients.

The Impact of COPD on in-Hospital Outcomes in Patients with Takotsubo Cardiomyopathy

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a known comorbidity of takotsubo cardiomyopathy (TCM), and COPD exacerbation is a potential triggering factor of TCM. The association between COPD and in-hospital outcomes and complications among TCM patients is not well established. We sought to assess the effect of COPD on hospitalized patients with a primary diagnosis of TCM.

METHODS

We conducted a retrospective cohort study in patients with a primary diagnosis of TCM with or without COPD using the latest National Inpatient Sample from 2016-2017. We identified 3139 patients admitted with a primary diagnosis of TCM by the ICD-10-CM coding system; 684 of those patients also had a diagnosis of COPD. We performed propensity score matching in a 1:2 ratio (n=678 patients, matched COPD group; n=1070, matched non-COPD group) and compared in-hospital outcomes and complications between TCM patients with and without a COPD diagnosis.

RESULTS

Before matching, the COPD group had worse outcomes compared with the non-COPD group in inpatient death (2.9% vs 1.3%, p=0.006), length of stay (LOS) (4.02±2.99 days vs 3.27±3.39 days, p<0.001), hospitalization charges ($55,242.68±47,637.40 vs $48,316.97±47,939.84, p=0.001), and acute respiratory failure (ARF) (22.5% vs 7.7%, p<0.001), respectively. After propensity score matching, the matched COPD group, compared with the matched non-COPD group, had a higher inpatient mortality rate (2.9% vs1.0%, p=0.005), longer LOS (4.02±3.00 days vs 3.40±3.54 days, p<0.001), higher hospitalization charges ($55,409.23±47,809.13 vs $46,469.60±42,209.10, p<0.001), and a higher incidence of ARF (22.6% vs 8.2%, p<0.001) and cardiogenic shock (5.6% vs 3.3%, p=0.024), respectively.

CONCLUSION

Patients with COPD who are hospitalized for TCM have higher rates of inpatient mortality, ARF, cardiogenic shock, as well as a longer LOS, and higher charges of stay than those without COPD. Prospective studies are warranted to examine the effect of early intervention or treatment of COPD on short- and long-term outcomes of TCM.

‘Tax-otsubo’: stress cardiomyopathy following an encounter with the Inland Revenue

An 89-year-old man developed chest pain and palpitations shortly after finishing a stressful 40 min phone call to HM Revenue and Customs. After admission to the emergency department, he had a cardiovascular collapse followed soon after by a cardiac arrest due to ventricular fibrillation (VF). The troponin T was elevated and his ECG showed extensive deep T wave inversion with prolongation of the QT interval. A portable hand-held ultrasound device (VScan; GE Healthcare) was used to demonstrate classical apical ballooning of the left ventricular apex indicating a diagnosis of takotsubo stress cardiomyopathy. Shortly following admission to the cardiac care unit, he had a further episode of VF, which was successfully defibrillated. A coronary angiogram was performed, which was normal. He was treated with a short course of benzodiazepines. He was discharged after 8 days without any neurological deficit. His echocardiogram subsequently showed complete resolution of the abnormalities of the left ventricular function.

Myocardial and Systemic Inflammation in Acute Stress-Induced (Takotsubo) Cardiomyopathy

BACKGROUND

Acute stress-induced (takotsubo) cardiomyopathy can result in a heart failure phenotype with a prognosis comparable with that of myocardial infarction. In this study, we hypothesized that inflammation is central to the pathophysiology and natural history of takotsubo cardiomyopathy.

METHODS

In a multicenter study, we prospectively recruited 55 patients with takotsubo cardiomyopathy and 51 age-, sex-, and comorbidity-matched control subjects. During the index event and at the 5-month follow-up, patients with takotsubo cardiomyopathy underwent multiparametric cardiac magnetic resonance imaging, including ultrasmall superparamagnetic particles of iron oxide (USPIO) enhancement for detection of inflammatory macrophages in the myocardium. Blood monocyte subpopulations and serum cytokines were assessed as measures of systemic inflammation. Matched control subjects underwent investigation at a single time point.

RESULTS

Subjects were predominantly middle-aged (64±14 years) women (90%). Compared with control subjects, patients with takotsubo cardiomyopathy had greater USPIO enhancement (expressed as the difference between pre-USPIO and post-USPIO T2*) in both ballooning (14.3±0.6 milliseconds versus 10.5±0.9 milliseconds; P<0.001) and nonballooning (12.9±0.6 milliseconds versus 10.5±0.9 milliseconds; P=0.02) left ventricular myocardial segments. Serum interleukin-6 (23.1±4.5 pg/mL versus 6.5±5.8 pg/mL; P<0.001) and chemokine (C-X-C motif) ligand 1 (1903±168 pg/mL versus 1272±177 pg/mL; P=0.01) concentrations and classic CD14⁺⁺CD16^- monocytes (90±0.5% versus 87±0.9%; P=0.01) were also increased whereas intermediate CD14⁺⁺CD16⁺ (5.4±0.3% versus 6.9±0.6%; P=0.01) and nonclassic CD14⁺CD16⁺⁺ (2.7±0.3% versus 4.2±0.5%; P=0.006) monocytes were reduced in patients with takotsubo cardiomyopathy. At 5 months, USPIO enhancement was no longer detectable in the left ventricular myocardium, although persistent elevations in serum interleukin-6 concentrations ( P=0.009) and reductions in intermediate CD14⁺⁺CD16⁺ monocytes (5.6±0.4% versus 6.9±0.6%; P=0.01) remained.

CONCLUSIONS

We demonstrate for the first time that takotsubo cardiomyopathy is characterized by a myocardial macrophage inflammatory infiltrate, changes in the distribution of monocyte subsets, and an increase in systemic proinflammatory cytokines. Many of these changes persisted for at least 5 months, suggesting a low-grade chronic inflammatory state.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02897739.

The Impact of Emergency Interventions and Patient Characteristics on the Risk of Heart Failure in Patients with Nontraumatic OHCA

Background

Since out-of-hospital cardiac arrest- (OHCA-) related dysfunction (ischemic/reperfusion injury and inflammatory response) might result in long-term impairment, we suspect that new-onset heart failure might be common in long-term survivors. However, these relationships had not been well addressed, and we aimed to analyze the impact of emergency interventions and patient characteristics on the risk of new-onset heart failure in patients with nontraumatic OHCA.

Methods

The Taiwanese government healthcare database contains data for 49,101 nontraumatic OHCA adult patients from 2011-2012, which were analyzed in this study. Nontraumatic OHCA patients who survived to the intensive care unit (ICU) were included as the study group (n = 7,321). Matched patients (n = 21,963) were recruited as a comparison group. Patients with any history of heart failure or cardiac arrest were not included in either group. All patients were followed-up for 6 months for the identification of new-onset heart failure. Adjustments were made for demographics, age, emergency interventions, and comorbidities as potential risk factors.

Results

In all, 3.84% (n = 281) of OHCA patients suffered new-onset heart failure, while only 1.24% (n = 272) of matched patients in the comparison group suffered new-onset heart failure. Strong risk factors for heart failure were age (60-75 years, HR: 11.4; 95% CI: 9-14.4), medical history (myocardial infarction, HR: 2.47; 95% CI: 2.05-2.98 and cardiomyopathy, HR: 2.94; 95% CI: 1.45-5.94), and comorbidities during hospitalization (ischemic heart disease, HR: 4.5; 95% CI: 3.46-5.86). Only extracorporeal membrane oxygenation (ECMO) decreased the risk of heart failure. Most (53.6%) heart failure events occurred within 60 days after OHCA.

Conclusion

An age from 61 to 75 years, a history of myocardial infarction or cardiomyopathy, and ischemic heart disease or infection as comorbidities occurring during hospitalization were strong risk factors for new-onset heart failure in OHCA patients. However, ECMO could decrease this risk. More importantly, most heart failure events occurred within 60 days after OHCA.

Significance of Asymptomatic Hyper Creatine-Kinase Emia

OBJECTIVES

Whether asymptomatic hyper-CKemia (AHCE) should prompt a thorough work-up for muscle disease or not is controversially discussed. This review aims at summarizing and discussing recent findings concerning the cause, frequency, evolution, and work-up of conditions manifesting as AHCE and normal or abnormal electromyography (EMG) respectively muscle biopsy.

METHODS

Systematic PubMed search.

RESULTS

There are numerous primary (hereditary) and acquired myopathies that manifest with permanent, recurrent, or temporary AHCE with/without myopathic EMG or muscle biopsy. AHCE particularly occurs at onset of these conditions, which include dystrophinopathies, myotilinopathies, calpainopathy, caveolinopathy, dysferlinopathy, central core disease, multicore disease, desminopathy, MD1, MD2, hypoPP, malignant hyperthermia susceptibility, Pompe disease, McArdle disease, myoadenylate deaminase-deficiency, CPT2-deficiency, mitochondrial disorders, or myopathy with tubular aggregates. Most likely, other primary myopathies manifest with AHCE as well, without having been reported. Patients with AHCE should be taken seriously and repeated CK determination must be conducted. If hyper-CKemia is persisting or recurrent, these patients should undergo an EMG and eventually muscle biopsy. If noninformative, genetic work-up by a panel or whole exome sequencing should be initiated, irrespective of the family history. Patients with AHCE should avoid excessive exercise, require sufficient hydration, require counseling with regard to the risk of malignant hyperthermia, and should inform anesthesiologists and surgeons about their condition before elective surgery.

CONCLUSIONS

Recurrent AHCE should be taken seriously and managed with conventional work-up. If noninformative, genetic work-up should follow irrespective of the family history.

Reversible stress cardiomyopathy in Guillain-Barré syndrome: a case report

Background

Case Presentation

Conclusions

Neurogenic Stunned Myocardium in Two Children with Neurological Injury

Neurogenic stunned myocardium is described as sudden and reversible cardiac dysfunction induced by an acute neurological event. This phenomenon has not been thoroughly investigated in infants, and is probably underdiagnosed. Here, we report the cases of two infants with neurogenic stunned myocardium in whom the clinical suspicion was relevant, with a brief discussion of this condition.

A case report of cerebral arterial gas embolism (CAGE) associated with Takotsubo cardiomyopathy

A 43-year-old female scuba diver was retrieved and treated following a rapid ascent and presumed cerebral arterial gas embolism (CAGE). She subsequently developed respiratory distress and was found to have Takotsubo cardiomyopathy, with transient left ventricular dysfunction, elevated cardiac enzymes, and normal CT coronary angiography. We believe this to be the first report of CAGE associated with Takotsubo cardiomyopathy.

Reverse Takotsubo Cardiomyopathy in a Patient With Prior Apical Takotsubo Cardiomyopathy: Challenging the Beta Receptor Gradient Theory

Background: Classic Takotsubo cardiomyopathy has been described as transient apical dyskinesia following major stress that is believed to be related to catecholamine surges. Atypical variants have been described, including the rarer reverse Takotsubo cardiomyopathy. Discrepant gradients of the beta-2 adrenoceptors are thought to determine the different anatomic variants. Case Report: A 43-year-old female presented with chest pain and a mild troponin elevation. Echocardiography and coronary angiography were consistent with stress-induced apical Takotsubo cardiomyopathy. Eight months later, the patient was admitted with a similar presentation; however, workup revealed stress-induced reverse Takotsubo cardiomyopathy. Conclusion: Recurrent Takotsubo cardiomyopathy involving different anatomic regions of the left ventricle is a rare phenomenon yet appears to be similar to typical Takotsubo cardiomyopathy in presentation and hospital course. Chronic therapy with beta blockers and angiotensin-converting enzyme inhibitors did not prevent a recurrence in this patient, suggesting that optimum treatment needs to be determined. Takotsubo cardiomyopathy affecting different myocardial segments may recur in the same patient, implying that the adrenoceptor distribution theory needs further refinement.